Initial experience with laparoscopic and robotic surgery for the treatment of periampullary tumours: single institution experience with the first 30 consecutive cases

Abstract

Background: Concerns have been raised about the safety of minimally invasive surgery (MIS) for pancreatoduodenectomy (PD) during the early learning phase. In this study, we present our initial experience with MIS for periampullary tumours. Methods: Retrospective review of the first 30 consecutive patients who underwent laparoscopic (LS)/robotic surgery (RS) for periampullary tumours between 2014 and 2017. Results: Twenty-seven patients underwent PD, including three total pancreatectomies (TPs) and three underwent palliative bypasses. Twenty underwent LS, of which 18 were hybrid PDs, including two TPs and two bypasses. Ten patients underwent RS, of which nine were PDs, including one TP and one bypass. Five of 10 RSs were totally MIS procedures. There were four PDs with venous resection, of which three were by RS. There were four (13.3%) open conversions all in the LS cohort. There were five (16.7%) major (>grade 2) morbidities, including three pancreatic fistulas (two grade B and one grade C). There was no 30-day and one (3.3%) 90-day mortality. Comparison between RS and LS demonstrated that RS had a higher likelihood of being completed via totally MIS (five (50%) versus 0, P = 0.002), tended to have a shorter post-operative stay (eight (range 6-36) versus 14.5 (range 6-62) days, P = 0.058) but tended to be associated with a longer operation time (670 (range 500-930) versus 577 (range 235-715) min, P = 0.056). Conclusion: Our initial experience demonstrated that both LS and RS can be safely adopted for the treatment of periampullary tumours. The learning curve for RS seemed to be shorter than LS as we could transition more quickly from hybrid PDs to totally MIS safely. © 2019 Royal Australasian College of Surgeons ANZ J Surg 89 (2019) E137-E141 ANZJSurg.com E138 Goh et al.

Initial single institution experience with robotic biliary surgery and bilio‐enteric anastomosis in southeast Asia

“…Despite this being our early experience, we found RBS to be safe and feasible as evidenced by the absence of open conversions or mortality and the low morbidity rate. Nonetheless, it is important to highlight, that we had concomitant experience with a high volume of major laparoscopic and robotic HPB surgery during the study period [3][4][5]31 which would have partially accounted for our favourable outcomes and relatively short learning curve. Although it is widely reported that robotic surgery allows 'open' surgeons to transition more quickly to MIS compared to laparoscopy with shorter learning curve, in our experience the learning curve for experienced laparoscopic surgeons is even shorter.…”

“…In our experience, robotic surgery enhances the individual capabilities of a laparoscopic surgeon allowing him/her to perform even more complex tasks such as difficult fine suturing which he would otherwise be less comfortable with. 4,25,31 The main barrier to the widespread use of robotic surgery today is the increased cost associated with the procedure resulting in limited access to both patients and surgeons to the technology. 4 Due to the high cost of purchasing and for maintenance of the robot; few surgeons worldwide have regular access to this technology for training.…”

“…The straight and rigid conventional laparoscopic instruments with limited degrees of freedom hinder the performance of a precise, tension-free anastomosis (8.25) especially in the tight narrow space of the proximal hepatic hilum. Nonetheless, it is important to highlight, that we had concomitant experience with a high volume of major laparoscopic and robotic HPB surgery during the study period [3][4][5]31 which would have partially accounted for our favourable outcomes and relatively short learning curve. 8 Robotic instruments with their increase range of motion due to the Endowrist results in superior dexterity and precision.…”

“…Hence, it is not surprising that anastomotic complications such as bile leak and strictures remain a significant concern after conventional laparoscopic bilio-enteric anastomosis especially during the learning curve. 4,25,31 The main barrier to the widespread use of robotic surgery today is the increased cost associated with the procedure resulting in limited access to both patients and surgeons to the technology. This theoretically allows complex manoeuvres such as fine intracorporeal suturing during hepaticojejunostomy to be performed with greater precision.…”

“…The port placement and technique for robotic pancreatoduodenectomies have been described previously. 4,31 Various techniques were used for the bilio-enteric anastomosis. For large ducts, continuous running prolene 3-0/4-0 or barbed sutures (V-Loc; Medtronic, Minneapolis, MN, USA) were used.…”